The Victorian Ombudsman's Investigation Into Deaths and Harm In Custody report comes a week after a coroner handed down her findings about a man who died in 2009 while in custody in an Echuca police cell.

A Victorian Ombudsman report about deaths and self-harm in custody has been released a week to the day after a coroner released her findings about the 2009 police cell death of Stephen Niit.

On Tuesday, Victorian Ombudsman George Brouwer released the Investigation Into Deaths and Harm In Custodyreport, which looked at the number of deaths and incidences of self-harm in Victorian custodial facilities from 2008-13.

Four out of six Victoria Police cell deaths between 2008 and 2013 occurred in 2009-10, according to the report.

One of the deaths was paramedic Stephen Niit, who died on December 22, 2009, after hanging himself in an Echuca police cell while in custody for being intoxicated.

Victorian Coroner Jacinta Heffey handed down her findings into Mr Niit’s death to the Melbourne Coroner’s Court on March 18.

On March 19, the Riverine Heraldreported that Ms Heffey found inadequate police resourcing, miscommunication, relaxing of police guidelines for keeping a person in custody and only a basic understanding of mental health arrest laws contributed to Mr Niit’s death.

Some of the concerns raised by Ms Heffey regarding keeping drug or alcohol-affected mental health patients in custody were mirrored in Mr Brouwer’s report, particularly a concern with an increase in the number of vulnerable detainees in custody.

‘‘Many people in custody are vulnerable, often with complex social, legal and medical histories, including mental health, drug and alcohol problems,’’ the report said.

Among the ombudsman’s recommendations to Victoria Police was to review the provision of service for both general medical services and mental health services provided to detainees in regional police cells.

Echuca Senior Sergeant Mick Carroll did not comment on the more recent ombudsman report but said police were reviewing the coroner's findings.

‘‘Victoria Police has received the coroner’s report and will now take time to review its findings,’’ he said.